Stents Work Well, But Are Costly: Will Hospitals Continue To Use Them?

NEW ORLEANS -- The current boom in implanting tubular devices called
stents in heart arteries may go bust when hospitals realize they are losing
their profit margins, a researcher has concluded in a study presented at
the annual meeting of the American Heart Association.

And if that happens, heart care will take several steps backward to
the detriment of patients, Duke University Medical Center cardiologist Dr.
Eric Peterson warned. "Sadly, hospitals now need to look at how every
dollar is spent, and 'stenting' may become a luxury they can't afford."

Cardiologists insert the mesh-like structures to keep arteries open
after clogs have been cleared by balloon angioplasty. Because of its effectiveness,
stenting has quickly become a popular procedure: This year, it is estimated
that 170,000 stents will be inserted in American hearts, compared to almost
none five years ago.

Peterson performed a detailed examination of the costs associated with
doing an angioplasty alone, or an angioplasty that delivers a stent. Analyzing
the results in about 400 patients, he found that stenting costs about $13,000
-- roughly $2,000 to $3,000 more than regular angioplasty.

To many cardiologists and patients, that extra expense is well worth
it, because inserting a stent structure in an artery has been proven to
reduce the rate of recurrent blockages in the artery, Peterson said.

But, depending on who is paying the bill, he said these procedures may
be a bad financial deal for the hospital.

Medicare gives hospitals one price (from $10,000 to $13,000 depending
on the kind of hospital) through its payment system to perform either an
angioplasty or an angioplasty that delivers a stent. And managed care companies
usually may pay much less than that, Peterson said. That means that, rather
than making a slight margin off a regular angioplasty, hospitals are losing
thousands of dollars every time a stent is used.

To date, cardiologists have not made decisions on whether to use a stent
or not based on how much money their hospitals make or lose, Peterson said.
In part, that's because the costs of stenting have fluctuated as the devices
and the procedure have been perfected. But the primary reason is that money
wasn't such an issue in the past. "Now, with the onset of managed care
and diminishing reimbursement from all payers, hospitals need to be very
cost conscious."

In looking at medical records, Peterson found out that the extra cost
of stenting is not due to medication or length of hospital stay. It is in
the fixed price of the devices, which usually cost around $1,600 each, and
the extra angioplasty balloons, costing up to $600 each, that are needed
to insert the stents.

So now what was a "win/win" situation for patients and society
-- better immediate outcomes and less need for repeat procedures -- has
become a losing proposition for hospitals, Peterson said. "A treatment
that carries a large financial burden may not stay popular," he said.

One obvious answer to the dilemma is to convince the Health Care Financing
Administration, the federal agency responsible for setting Medicare reimbursement
rates, to set two different prices for the two procedures. But so far, HCFA
has been unwilling to do this, Peterson said.

Another solution may be a capitated system of heart treatment, in which
a hospital receives a set amount of money to care for a single individual
over time. In that system, the benefit of stenting in reducing the need
for patients to return to the hospital will likely be recognized.

Peterson said that the trade-off between new, but costly, improvements
in patient care and the ability of hospitals and other providers to absorb
the differences in reimbursements will become more and more of an issue.
"These are growing problems that are going to concern hospitals in
the future when their economic motivations are increasingly placed in direct
conflict with their desire to do the best for patients," he said.

In a plenary session talk on "The Financial Fallout From the Stent
Explosion" to be given Wednesday morning at the conference, Dr. Daniel
Mark will review what is known about the benefits and costs of stenting
versus balloon angioplasty. Mark, director of the Duke Outcomes Research
and Assessment Group, said stenting does "reduce the need for repeat
angioplasty and bypass surgery during the year following the procedure.
Reduced follow-up procedures allow stenting to recoup some of the extra
costs associated with this form of therapy."

Up to 25 percent of patients who had angioplasty will need a repeat
procedure in the follow-up year, Mark said. With stenting, current evidence
is that the repeat procedure rate falls to about 16 percent, and to fully
pay back the extra costs of the procedure, current projections suggest that
the repeat procedure rate will need to fall to around 9 percent, Mark said.
"Ongoing trials including the latest stent technology will help define
how close doctors have come to achieving this level of effectiveness,"
he said.

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